Category: Mental Health History

What is a Double Bind?

Published on by Andrew Marshall2 Comments

Introduction

A double bind is a dilemma in communication in which an individual (or group) receives two or more conflicting messages, with one negating the other. In some circumstances (particularly families and relationships) this might be emotionally distressing. This creates a situation in which a successful response to one message results in a failed response to the other (and vice versa), so that the person will automatically be wrong regardless of response. The double bind occurs when the person cannot confront the inherent dilemma, and therefore can neither resolve it nor opt out of the situation.

Double bind theory was first described by Gregory Bateson and his colleagues in the 1950s.

Double binds are often utilised as a form of control without open coercion – the use of confusion makes them difficult both to respond to and to resist.

A double bind generally includes different levels of abstraction in the order of messages and these messages can either be stated explicitly or implicitly within the context of the situation, or they can be conveyed by tone of voice or body language. Further complications arise when frequent double binds are part of an ongoing relationship to which the person or group is committed.

Refer to Family Therapy and the Bateson Project (1953-1963).

Explanation

The double bind is often misunderstood to be a simple contradictory situation, where the subject is trapped by two conflicting demands. While it is true that the core of the double bind is two conflicting demands, the difference lies in how they are imposed upon the subject, what the subject’s understanding of the situation is, and who (or what) imposes these demands upon the subject. Unlike the usual no-win situation, the subject has difficulty in defining the exact nature of the paradoxical situation in which they are caught. The contradiction may be unexpressed in its immediate context and therefore invisible to external observers, only becoming evident when a prior communication is considered. Typically, a demand is imposed upon the subject by someone whom they respect (such as a parent, teacher, or doctor) but the demand itself is inherently impossible to fulfil because some broader context forbids it. For example, this situation arises when a person in a position of authority imposes two contradictory conditions but there exists an unspoken rule that one must never question authority.

Gregory Bateson and his colleagues defined the double bind as follows:

  1. The situation involves two or more people, one of whom (for the purpose of the definition), is designated as the “subject”. The others are people who are considered the subject’s superiors: figures of authority (such as parents), whom the subject respects.
  2. Repeated experience: the double bind is a recurrent theme in the experience of the subject, and as such, cannot be resolved as a single traumatic experience.
  3. A ‘primary injunction’ is imposed on the subject by the others generally in one of two forms:
    • (a) “Do X, or I will punish you”; or
    • (b) “Do not do X, or I will punish you.”
    • The punishment may include the withdrawing of love, the expression of hate and anger, or abandonment resulting from the authority figure’s expression of helplessness.
  4. A ‘secondary injunction’ is imposed on the subject, conflicting with the first at a higher and more abstract level. For example: “You must do X, but only do it because you want to.” It is unnecessary for this injunction to be expressed verbally.
  5. If necessary, a ‘tertiary injunction’ is imposed on the subject to prevent them from escaping the dilemma.
    • See phrase examples below for clarification.
  6. Finally, Bateson states that the complete list of the previous requirements may be unnecessary, in the event that the subject is already viewing their world in double bind patterns. Bateson goes on to give the general characteristics of such a relationship:
    • When the subject is involved in an intense relationship; that is, a relationship in which he feels it is vitally important that he discriminate accurately what sort of message is being communicated so that he may respond appropriately;
    • And, the subject is caught in a situation in which the other person in the relationship is expressing two orders of message and one of these denies the other;
    • And, the subject is unable to comment on the messages being expressed to correct his discrimination of what order of message to respond to: i.e., he cannot make a metacommunicative statement.

Thus, the essence of a double bind is two conflicting demands, each on a different logical level, neither of which can be ignored or escaped. This leaves the subject torn both ways, so that whichever demand they try to meet, the other demand cannot be met. “I must do it, but I can’t do it” is a typical description of the double-bind experience.

For a double bind to be effective, the subject must be unable to confront or resolve the conflict between the demand placed by the primary injunction and that of the secondary injunction. In this sense, the double bind differentiates itself from a simple contradiction to a more inexpressible internal conflict, where the subject really wants to meet the demands of the primary injunction, but fails each time through an inability to address the situation’s incompatibility with the demands of the secondary injunction. Thus, subjects may express feelings of extreme anxiety in such a situation, as they attempt to fulfil the demands of the primary injunction albeit with obvious contradictions in their actions.

This was a problem in United States legal circles prior to the Fifth Amendment to the United States Constitution being applied to state action. A person could be subpoenaed to testify in a federal case and given Fifth Amendment immunity for testimony in that case. However, since the immunity did not apply to a state prosecution, the person could refuse to testify at the Federal level despite being given immunity, thus subjecting the person to imprisonment for contempt of court, or the person could testify, and the information they were forced to give in the Federal proceeding could then be used to convict the person in a state proceeding.

Brief History

The term double bind was first used by the anthropologist Gregory Bateson and his colleagues (including Don D. Jackson, Jay Haley and John H. Weakland) in the mid-1950s in their discussions on complexity of communication in relation to schizophrenia. Bateson made clear that such complexities are common in normal circumstances, especially in “play, humour, poetry, ritual and fiction” (see Logical Types below). Their findings indicated that the tangles in communication often diagnosed as schizophrenia are not necessarily the result of an organic brain dysfunction. Instead, they found that destructive double binds were a frequent pattern of communication among families of patients, and they proposed that growing up amidst perpetual double binds could lead to learned patterns of confusion in thinking and communication.

Complexity in Communication

Human communication is complex, and context is an essential part of it. Communication consists of the words said, tone of voice, and body language. It also includes how these relate to what has been said in the past; what is not said, but is implied; how these are modified by other nonverbal cues, such as the environment in which it is said, and so forth. For example, if someone says “I love you”, one takes into account who is saying it, their tone of voice and body language, and the context in which it is said. It may be a declaration of passion or a serene reaffirmation, insincere and/or manipulative, an implied demand for a response, a joke, its public or private context may affect its meaning, and so forth.

Conflicts in communication are common and often we ask “What do you mean?” or seek clarification in other ways. This is called meta-communication: communication about the communication. Sometimes, asking for clarification is impossible. Communication difficulties in ordinary life often occur when meta-communication and feedback systems are lacking or inadequate or there is not enough time for clarification.

Double binds can be extremely stressful and become destructive when one is trapped in a dilemma and punished for finding a way out. But making the effort to find the way out of the trap can lead to emotional growth.

Examples

The classic example given of a negative double bind is of a mother telling her child that she loves them, while at the same time turning away in disgust, or inflicting corporal punishment as discipline: the words are socially acceptable; the body language is in conflict with it. The child does not know how to respond to the conflict between the words and the body language and, because the child is dependent on the mother for basic needs, they are in a quandary. Small children have difficulty articulating contradictions verbally and can neither ignore them nor leave the relationship.

Another example is when one is commanded to “be spontaneous”. The very command contradicts spontaneity, but it only becomes a double bind when one can neither ignore the command nor comment on the contradiction. Often, the contradiction in communication is not apparent to bystanders unfamiliar with previous communications.

Phrase Examples

  • An example from Gerald M. Weinberg in a non-family situation…. “I suggest you find someone who you feel is more capable in this role”.
    • This requires the recipient to either confirm that the current incumbent in the role is sufficiently capable, or accept that they choose someone else based on their feelings – not an objective assessment of whether the incumbent is capable.
  • Mother telling her child: “You must love me”.
  • The primary injunction here is the command itself: “you must”; the secondary injunction is the unspoken reality that love is spontaneous, that for the child to love the mother genuinely, it can only be of their own accord.
  • Child-abuser to child: “You should have escaped from me earlier, now it’s too late—because now, nobody will believe that you didn’t want what I have done”, while at the same time blocking all of the child’s attempts to escape.
  • Child-abusers often start the double-bind relationship by “grooming” the child, giving little concessions, or gifts or privileges to them, thus the primary injunction is: “You should like what you are getting from me!”
  • When the child begins to go along (i.e. begins to like what they are receiving from the person), then the interaction goes to the next level and small victimisation occurs, with the secondary injunction being: “I am punishing you! (for whatever reason the child-abuser is coming up with, e.g. “because you were bad/naughty/messy”, or “because you deserve it”, or “because you made me do it”, etc.).
  • If child shows any resistance (or tries to escape) from the abuser, then the words: “You should have escaped from me earlier (…)” serve as the third level or tertiary injunction.
  • Then the loop starts to feed on itself, allowing for ever worse victimisation to occur.
  • Mother to son: “Leave your sister alone!”, while the son knows his sister will approach and antagonize him to get him into trouble.
  • The primary injunction is the command, which he will be punished for breaking.
    • The secondary injunction is the knowledge that his sister will get into conflict with him, but his mother will not know the difference and will default to punishing him.
    • He may be under the impression that if he argues with his mother, he may be punished.
    • One possibility for the son to escape this double bind is to realise that his sister only antagonises him to make him feel anxious (if indeed it is the reason behind his sister’s behaviour).
  • If he were not bothered about punishment, his sister might not bother him.
    • He could also leave the situation entirely, avoiding both the mother and the sister.
    • The sister can not claim to be bothered by a non-present brother, and the mother can not punish (or scapegoat) a non-present son.
    • Other solutions exist too, which are based on the creative application of logic and reasoning.
  • An apt reply would be: “Please tell sis the same”. If mother wants to ‘scapegoat’ him, her response will be negative.
    • The command has a negative undertone towards the son.

Positive Double Binds

Bateson also described positive double binds, both in relation to Zen Buddhism with its path of spiritual growth, and the use of therapeutic double binds by psychiatrists to confront their patients with the contradictions in their life in such a way that would help them heal. One of Bateson’s consultants, Milton H. Erickson (5 volumes, edited by Rossi) eloquently demonstrated the productive possibilities of double binds through his own life, showing the technique in a brighter light.

The Science

One of the causes of double binds is the loss of feedback systems. Gregory Bateson and Lawrence S. Bale describe double binds that have arisen in science that have caused decades-long delays of progress in science because the scientific community had defined something as outside of its scope (or as “not science”) – see Bateson in his Introduction to Steps to an Ecology of Mind (1972, 2000), pp.xv–xxvi; and Bale in his article, Gregory Bateson, Cybernetics and the Social/Behavioural Sciences (esp. pp.1-8) on the paradigm of classical science vs. that of systems theory/cybernetics. (See also Bateson’s description in his Forward of how the double bind hypothesis fell into place).

Work by Bateson

Schizophrenia

The Double Bind Theory was first articulated in relationship to schizophrenia, but Bateson and his colleagues hypothesized that schizophrenic thinking was not necessarily an inborn mental disorder but a learned confusion in thinking.

It is helpful to remember the context in which these ideas were developed. Bateson and his colleagues were working in the Veteran’s Administration Hospital (1949-1962) with World War II veterans. As soldiers they’d been able to function well in combat, but the effects of life-threatening stress had affected them. At that time, 18 years before Post-Traumatic Stress Disorder was officially recognised, the veterans had been saddled with the catch-all diagnosis of schizophrenia. Bateson did not challenge the diagnosis but he did maintain that the seeming nonsense the patients said at times did make sense within context, and he gives numerous examples in section III of Steps to an Ecology of Mind, “Pathology in Relationship”. For example, a patient misses an appointment, and when Bateson finds him later the patient says ‘the judge disapproves’; Bateson responds, “You need a defense lawyer”. Bateson also surmised that people habitually caught in double binds in childhood would have greater problems – that in the case of the schizophrenic, the double bind is presented continually and habitually within the family context from infancy on. By the time the child is old enough to have identified the double bind situation, it has already been internalised, and the child is unable to confront it. The solution then is to create an escape from the conflicting logical demands of the double bind, in the world of the delusional system.

One solution to a double bind is to place the problem in a larger context, a state Bateson identified as Learning III, a step up from Learning II (which requires only learned responses to reward/consequence situations). In Learning III, the double bind is contextualized and understood as an impossible no-win scenario so that ways around it can be found.

Bateson’s double bind theory was never followed up by research into whether family systems imposing systematic double binds might be a cause of schizophrenia. This complex theory has been only partly tested, and there are gaps in the current psychological and experimental evidence required to establish causation. The current understanding of schizophrenia emphasizes the robust scientific evidence for a genetic predisposition to the disorder, with psychosocial stressors, including dysfunctional family interaction patterns, as secondary causative factors in some instances.

Evolution

After many years of research into schizophrenia, Bateson continued to explore problems of communication and learning, first with dolphins, and then with the more abstract processes of evolution. Bateson emphasised that any communicative system characterized by different logical levels might be subject to double bind problems. Especially including the communication of characteristics from one generation to another (genetics and evolution).

“…evolution always followed the pathways of viability. As Lewis Carroll has pointed out, the theory [of natural selection] explains quite satisfactorily why there are no bread-and-butter-flies today.”

Bateson used the fictional Bread and Butter Fly (from Through the Looking Glass, and What Alice Found There) to illustrate the double bind in terms of natural selection. The gnat points out that the insect would be doomed if he found his food (which would dissolve his own head, since this insect’s head is made of sugar, and his only food is tea), and starve if he did not. Alice suggests that this must happen quite often, to which the gnat replies: “It always happens.”

The pressures that drive evolution therefore represent a genuine double bind. And there is truly no escape: “It always happens.” No species can escape natural selection, including our own.

Bateson suggested that all evolution is driven by the double bind, whenever circumstances change: If any environment becomes toxic to any species, that species will die out unless it transforms into another species, in which case, the species becomes extinct anyway.

Most significant here is Bateson’s exploration of what he later came to call ‘the pattern that connects’ – that problems of communication which span more than one level (e.g. the relationship between the individual and the family) should also be expected to be found spanning other pairs of levels in the hierarchy (e.g. the relationship between the genotype and the phenotype):

“We are very far, then, from being able to pose specific questions for the geneticist; but I believe that the wider implications of what I have been saying modify somewhat the philosophy of genetics. Our approach to the problems of schizophrenia by way of a theory of levels or logical types has disclosed first that the problems of adaptation and learning and their pathologies must be considered in terms of a hierarchic system in which stochastic change occurs at the boundary points between the segments of the hierarchy. We have considered three such regions of stochastic change—the level of genetic mutation, the level of learning, and the level of change in family organization. We have disclosed the possibility of a relationship of these levels which orthodox genetics would deny, and we have disclosed that at least in human societies the evolutionary system consists not merely in the selective survival of those persons who happen to select appropriate environments but also in the modification of family environment in a direction which might enhance the phenotypic and genotypic characteristics of the individual members.”

Girard’s Mimetic Double Bind

René Girard, in his literary theory of mimetic desire, proposes what he calls a “model-obstacle”, a role model who demonstrates an object of desire and yet, in possessing that object, becomes a rival who obstructs fulfilment of the desire. According to Girard, the “internal mediation” of this mimetic dynamic “operates along the same lines as what Gregory Bateson called the ‘double bind’.” Girard found in Sigmund Freud’s psychoanalytic theory, a precursor to mimetic desire. “The individual who ‘adjusts’ has managed to relegate the two contradictory injunctions of the double bind—to imitate and not to imitate—to two different domains of application. This is, he divides reality in such a way as to neutralize the double bind.” While critical of Freud’s doctrine of the unconscious mind, Girard sees the ancient Greek tragedy, Oedipus Rex, and key elements of Freud’s Oedipus complex, patricidal and incestuous desire, to serve as prototypes for his own analysis of the mimetic double bind.

Far from being restricted to a limited number of pathological cases, as American theoreticians suggest, the double bind – a contradictory double imperative, or rather a whole network of contradictory imperatives – is an extremely common phenomenon. In fact, it is so common that it might be said to form the basis of all human relationships.

Bateson is undoubtedly correct in believing that the effects of the double bind on the child are particularly devastating. All the grown-up voices around him, beginning with those of the father and mother (voices which, in our society at least, speak for the culture with the force of established authority) exclaim in a variety of accents, “Imitate us!” “Imitate me!” “I bear the secret of life, of true being!” The more attentive the child is to these seductive words, and the more earnestly he responds to the suggestions emanating from all sides, the more devastating will be the eventual conflicts. The child possesses no perspective that will allow him to see things as they are. He has no basis for reasoned judgements, no means of foreseeing the metamorphosis of his model into a rival. This model’s opposition reverberates in his mind like a terrible condemnation; he can only regard it as an act of excommunication. The future orientation of his desires – that is, the choice of his future models – will be significantly affected by the dichotomies of his childhood. In fact, these models will determine the shape of his personality.

If desire is allowed its own bent, its mimetic nature will almost always lead it into a double bind. The unchanneled mimetic impulse hurls itself blindly against the obstacle of a conflicting desire. It invites its own rebuffs and these rebuffs will in turn strengthen the mimetic inclination. We have, then, a self-perpetuating process, constantly increasing in simplicity and fervor. Whenever the disciple borrows from his model what he believes to be the “true” object, he tries to possess that truth by desiring precisely what this model desires. Whenever he sees himself closest to the supreme goal, he comes into violent conflict with a rival. By a mental shortcut that is both eminently logical and self-defeating, he convinces himself that the violence itself is the most distinctive attribute of this supreme goal! Ever afterward, violence will invariably awaken desire… (René Girard, Violence and the Sacred: “From Mimetic Desire to the Monstrous Double”, pp.156-157).

Neuro-Linguistic Programming

The field of Neuro-Linguistic Programming (NLP) also makes use of the expression “double bind”. Grinder and Bandler (both of whom had personal contact with Bateson and Erickson) asserted that a message could be constructed with multiple messages, whereby the recipient of the message is given the impression of choice – although both options have the same outcome at a higher level of intention. This is called a “double bind” in NLP terminology, and has applications in both sales and therapy. In therapy, the practitioner may seek to challenge destructive double binds that limit the client in some way and may also construct double binds in which both options have therapeutic consequences. In a sales context, the speaker may give the respondent the illusion of choice between two possibilities. For example, a salesperson might ask: “Would you like to pay cash or by credit card?”, with both outcomes presupposing that the person will make the purchase; whereas the third option (that of not buying) is intentionally excluded from the spoken choices.

Note that in the NLP context, the use of the phrase “double bind” does not carry the primary definition of two conflicting messages; it is about creating a false sense of choice which ultimately binds to the intended outcome. In the “cash or credit card?” example, this is not a “Bateson double bind” since there is no contradiction, although it still is an “NLP double bind”. Similarly if a salesman were selling a book about the evils of commerce, it could perhaps be a “Bateson double bind” if the buyer happened to believe that commerce was evil, yet felt compelled or obliged to buy the book.

What was the Bateson Project?

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Introduction

The Bateson Project (1953-1963) was the name given to a ground-breaking collaboration organised by Gregory Bateson which was responsible for some of the most important papers and innovations in communication and psychotherapy in the 1950s and early 1960s. Its other members were Donald deAvila Jackson, Jay Haley, John Weakland, and Bill Fry.

Background

Perhaps their most famous and influential publication was Towards a Theory of Schizophrenia (1956), which introduced the concept of the Double Bind, and helped found Family Therapy.

One of the project’s first locations was the Menlo Park VA Hospital, which was chosen because of Bateson’s previous work there as an ethnologist. The initial research, which was funded by a Rockefeller grant, focused on “strange communication” and nonsensical language among the patients of the institution who were suffering from schizophrenia. The group studied this within the context of double bind communication in family dynamics.

Refer to Double Bind and Family Therapy.

On This Day … 04 April

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People (Deaths)

  • 2012 – A. Dean Byrd, American psychologist and academic (b. 1948).

A. Dean Byrd

Albert Dean Byrd (1948 to 4 April 2012) was a former president of the National Association for Research & Therapy of Homosexuality (NARTH), a research organisation that advocates sexual orientation change efforts (SOCE).

He was a psychologist who focused on SOCE, and wrote on the topic. Although raised by a Buddhist mother and a Baptist father, Byrd converted to The Church of Jesus Christ of Latter-day Saints (LDS Church) and was very active in the debate within the church on issues involving homosexuality.

Professional Life

Byrd was a well known supporter of conversion therapy, and authored more than 100 publications, including books, peer-reviewed scientific journals, law journals, book chapters, invited commentaries and opinion editorials, many of which addressed issues of human sexuality. In 2002, he presented a paper which describes a technique called gender-affirmative therapy. He stated: “The basic premise of gender-affirmative therapy is that social and emotional variables affect gender identity which, in turn, determines sexual orientation. The work of the therapist is to help people understand their gender development. Subsequently, such individuals are able to make choices that are consistent with their value system. The focus of therapy is to help clients fully develop their masculine or feminine identity”. He wrote several papers with Joseph Nicolosi. One of the largest was a survey of 882 people who were undergoing therapy, attending ex-gay groups or ex-gay conferences: 22.9% reported they had not undergone any changes, 42.7% reported some changes, and 34.3% reported much change in sexual orientation. As a group, they reported large reductions in homosexual thoughts and fantasies and improvements in their psychological, interpersonal, and spiritual well-being. He promoted his ideas on college campuses, in newspapers, and in several books. He was called as a professional witness to testify on behalf of Andrew McClintock, a Christian magistrate who was forced to resign due to his beliefs on homosexual parents. In 2007, he was asked to chair a symposium at the APA Convention in San Francisco.

Byrd received a Ph.D. in psychology from Brigham Young University (BYU), a post-doctoral degree in Child and Family Psychology from Virginia Commonwealth University and Medical College of Virginia, and a post-doctoral degree in Behavioral Medicine from Loyola University, Chicago. He also received both an M.P.H. from the University of Utah (U of U), School of Medicine, and an M.B.A. also from the U of U. He was a diplomate in forensic medicine.

Byrd served as the Director of Clinical Training for LDS Social Services, was a Clinical Professor at BYU, and was, at the time of his death, a Clinical Professor at the University of Utah, School of Medicine, with appointments in the Department of Family and Preventive Medicine and in Department of Psychiatry, with an adjunct clinical appointment in the Department of Family Studies, also at the University of Utah. As member of the faculty at the U of U, he lectured training medical students about disparities in health care in the population. He was also a member of the American Psychological Association, the Utah Psychological Association where he served on the governing board, with professional affiliations in the American Orthopsychiatric Association, where he was a fellow, the American Public Health Association, the American Board of Forensic Examiners and the Prescribing Psychologist Register, a training and credentialing organization for psychologists in psychopharmacology. He was also a former member of the Evergreen Board of Trustees. He was also the president of Thrasher Research Fund, a paediatric research granting institution. In 2007, he was elected as president of NARTH for 2008. Byrd had visiting professor appointments in Israel and Poland. He also had training in genetics, biochemistry and neurochemistry from the University of California at Berkeley.

Death

Byrd died of cancer on 04 April 2012.

On This Day … 03 April

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People (Births)

  • 1860 – Frederik van Eeden, Dutch psychiatrist and author (d. 1932).

Frederik van Eeden

Frederik Willem van Eeden (03 April 1860 to 16 June 1932) was a late 19th-century and early 20th-century Dutch writer and psychiatrist. He was a leading member of the Tachtigers and the Significs Group, and had top billing among the editors of De Nieuwe Gids (The New Guide) during its celebrated first few years of publication, starting in 1885.

Biography

Van Eeden was the son of Frederik Willem Van Eeden, director of the Royal Tropical Institute in Haarlem.

In 1880 he studied Medicine in Amsterdam, where he pursued a bohemian lifestyle and wrote poetry. Whilst living in the city, he coined the term lucid dream in the sense of mental clarity, a term that nowadays is a classic term in the Dream literature and study, meaning dreaming while knowing that one is dreaming. In his early writings, he was strongly influenced by Hindu ideas of selfhood, by Boehme’s mysticism, and by Fechner’s panpsychism.

He went on to become a prolific writer, producing many critically acclaimed novels, poetry, plays, and essays. He was widely admired in the Netherlands in his own time for his writings, as well as his status as the first internationally prominent Dutch psychiatrist.

Van Eeden’s psychiatrist practice included treating his fellow Tachtiger Willem Kloos as a patient starting in 1888. His treatment of Kloos was of limited benefit, as Kloos deteriorated into alcoholism and increasing symptoms of mental illness. Van Eeden also incorporated his psychiatric insights into his later writings, such as in a deeply psychological novel called “Van de koele meren des doods” (translated in English as “The Deeps of Deliverance”). Published in 1900, the novel intimately traced the struggle of a woman addicted to morphine as she deteriorated physically and mentally.

His best known written work, “De Kleine Johannes” (“Little Johannes”), which first appeared in the premiere issue of De Nieuwe Gids, was a fantastical adventure of an everyman who grows up to face the harsh realities of the world around him and the emptiness of hopes for a better afterlife, but ultimately finding meaning in serving the good of those around him. This ethic is memorialized in the line “Waar de mensheid is, en haar weedom, daar is mijn weg.” (“Where mankind is, and her woe, there is my path.”).

Van Eeden sought not only to write about, but also to practice, such an ethic. He established a commune named Walden (commune) [nl], taking inspiration from Thoreau’s book Walden, in Bussum, North Holland, where the residents tried to produce as much of their needs as they could themselves and to share everything in common, and where he took up a standard of living far below what he was used to. This reflected a trend toward socialism among the Tachtigers; another Tachtiger, Herman Gorter, was a founding member of the world’s first Communist political party, the Dutch Social-Democratic Party, in 1909.

Van Eeden visited the US. He had contacts with William James and other psychologists. He met Freud in Vienna, whom he practically introduced in the Netherlands. He corresponded with Hermann Hesse, Charles Lloyd Tuckey (medical hypnotist), Harold Williams (linguist) and was a friend of Peter Kropotkin, the Russian anarchist living in London (UK).

Van Eeden also had a keen interest in Indian philosophy. He translated many of Tagore’s works, including Gitanjali and short stories.

In late years of his life, Van Eeden became a Roman Catholic.

What is Coping (Psychology)?

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Introduction

Coping means to invest one’s own conscious effort, to solve personal and interpersonal problems, in order to try to master, minimise or tolerate stress and conflict.

The psychological coping mechanisms are commonly termed coping strategies or coping skills. The term coping generally refers to adaptive (constructive) coping strategies, that is, strategies which reduce stress. In contrast, other coping strategies may be coined as maladaptive, if they increase stress. Maladaptive coping is therefore also described, based on its outcome, as non-coping. Furthermore, the term coping generally refers to reactive coping, i.e. the coping response which follows the stressor. This differs from proactive coping, in which a coping response aims to neutralise a future stressor. Subconscious or unconscious strategies (e.g. defence mechanisms) are generally excluded from the area of coping.

The effectiveness of the coping effort depends on the type of stress, the individual, and the circumstances. Coping responses are partly controlled by personality (habitual traits), but also partly by the social environment, particularly the nature of the stressful environment.

Types of Coping Strategies

Hundreds of coping strategies have been identified. Classification of these strategies into a broader architecture has not been agreed upon. Researchers try to group coping responses rationally, empirically by factor analysis, or through a blend of both techniques. In the early days, Folkman and Lazarus split the coping strategies into four groups, namely problem-focused, emotion-focused, support-seeking, and meaning-making coping. Weiten has identified four types of coping strategies:

  1. Appraisal-focused (adaptive cognitive);
  2. Problem-focused (adaptive behavioural);
  3. Emotion-focused; and
  4. Occupation-focused coping.

Billings and Moos added avoidance coping as one of the emotion-focused coping. Some scholars have questioned the psychometric validity of forced categorisation as those strategies are not independent to each other. Besides, in reality, people can adopt multiple coping strategies simultaneously.

Typically, people use a mixture of several coping strategies, which may change over time. All these strategies can prove useful, but some claim that those using problem-focused coping strategies will adjust better to life. Problem-focused coping mechanisms may allow an individual greater perceived control over their problem, whereas emotion-focused coping may sometimes lead to a reduction in perceived control (maladaptive coping).

Lazarus “notes the connection between his idea of ‘defensive reappraisals’ or cognitive coping and Freud’s concept of ‘ego-defenses'”, coping strategies thus overlapping with a person’s defence mechanisms.

Appraisal-Focused Coping Strategies

Appraisal-focused (adaptive cognitive) strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humour in a situation: “some have suggested that humor may play a greater role as a stress moderator among women than men”.

Adaptive Behavioural Coping Strategies

People using problem-focused strategies try to deal with the cause of their problem. They do this by finding out information on the problem and learning new skills to manage the problem. Problem-focused coping is aimed at changing or eliminating the source of the stress. The three problem-focused coping strategies identified by Folkman and Lazarus are: taking control, information seeking, and evaluating the pros and cons. However, problem-focused coping may not be necessarily adaptive, especially in the uncontrollable case that one cannot make the problem go away.

Emotion-Focused Coping Strategies

Emotion-focused strategies involve:

  • Releasing pent-up emotions.
  • Distracting oneself.
  • Managing hostile feelings.
  • Meditating.
  • Mindfulness practices.
  • Using systematic relaxation procedures.

Emotion-focused coping “is oriented toward managing the emotions that accompany the perception of stress”. The five emotion-focused coping strategies identified by Folkman and Lazarus are:

  • Disclaiming.
  • Escape-avoidance.
  • Accepting responsibility or blame.
  • Exercising self-control.
  • Positive reappraisal.

Emotion-focused coping is a mechanism to alleviate distress by minimizing, reducing, or preventing, the emotional components of a stressor. This mechanism can be applied through a variety of ways, such as:

  • Seeking social support.
  • Reappraising the stressor in a positive light.
  • Accepting responsibility.
  • Using avoidance.
  • Exercising self-control.
  • Distancing.

The focus of this coping mechanism is to change the meaning of the stressor or transfer attention away from it. For example, reappraising tries to find a more positive meaning of the cause of the stress in order to reduce the emotional component of the stressor. Avoidance of the emotional distress will distract from the negative feelings associated with the stressor. Emotion-focused coping is well suited for stressors that seem uncontrollable (e.g. a terminal illness diagnosis, or the loss of a loved one). Some mechanisms of emotion focused coping, such as distancing or avoidance, can have alleviating outcomes for a short period of time, however they can be detrimental when used over an extended period. Positive emotion-focused mechanisms, such as seeking social support, and positive re-appraisal, are associated with beneficial outcomes. Emotional approach coping is one form of emotion-focused coping in which emotional expression and processing is used to adaptively manage a response to a stressor. Other examples include relaxation training through deep breathing, meditation, yoga, music and art therapy, and aromatherapy, as well as grounding, which uses physical sensations or mental distractions to refocus from the stressor to present.

Reactive and Proactive Coping

Most coping is reactive in that the coping is in response to stressors. Anticipating and reacting to a future stressor is known as proactive coping or future-oriented coping. Anticipation is when one reduces the stress of some difficult challenge by anticipating what it will be like and preparing for how one is going to cope with it.

Social Coping

Social coping recognises that individuals are bedded within a social environment, which can be stressful, but also is the source of coping resources, such as seeking social support from others.

Humour

Humour used as a positive coping strategy may have useful benefits in relation to mental health and well-being. By having a humorous outlook on life, stressful experiences can be and are often minimised.

This coping method corresponds with positive emotional states and is known to be an indicator of mental health. Physiological processes are also influenced within the exercise of humour. For example, laughing may reduce muscle tension, increase the flow of oxygen to the blood, exercise the cardiovascular region, and produce endorphins in the body.

Using humour in coping while processing through feelings can vary depending on life circumstance and individual humour styles. In regards to grief and loss in life occurrences, it has been found that genuine laughs/smiles when speaking about the loss predicted later adjustment and evoked more positive responses from other people. A person of the deceased family member may resort to making jokes of when the deceased person used to give unwanted “wet willies” (term used for when a person sticks their finger inside their mouth then inserts the finger into another person’s ear) to any unwilling participant. A person might also find comedic relief with others around irrational possible outcomes for the deceased funeral service.

It is also possible that humour would be used by people to feel a sense of control over a more powerless situation and used as way to temporarily escape a feeling of helplessness. Exercised humour can be a sign of positive adjustment as well as drawing support and interaction from others around the loss.

Negative Techniques (Maladaptive Coping or Non-Coping)

Whereas adaptive coping strategies improve functioning, a maladaptive coping technique (also termed non-coping) will just reduce symptoms while maintaining or strengthening the stressor. Maladaptive techniques are only effective as a short-term rather than long-term coping process.

Examples of maladaptive behaviour strategies include dissociation, sensitization, safety behaviours, anxious avoidance, rationalisation and escape (including self-medication).

These coping strategies interfere with the person’s ability to unlearn, or break apart, the paired association between the situation and the associated anxiety symptoms. These are maladaptive strategies as they serve to maintain the disorder.

Dissociation is the ability of the mind to separate and compartmentalise thoughts, memories, and emotions. This is often associated with post traumatic stress syndrome.

Sensitization is when a person seeks to learn about, rehearse, and/or anticipate fearful events in a protective effort to prevent these events from occurring in the first place.

Safety behaviours are demonstrated when individuals with anxiety disorders come to rely on something, or someone, as a means of coping with their excessive anxiety.

Rationalisation is the practice of attempting to use reasoning to minimise the severity of an incident, or avoid approaching it in ways that could cause psychological trauma or stress. It most commonly manifests in the form of making excuses for the behaviour of the person engaging in the rationalisation, or others involved in the situation the person is attempting to rationalise.

Anxious avoidance is when a person avoids anxiety provoking situations by all means. This is the most common method.

Escape is closely related to avoidance. This technique is often demonstrated by people who experience panic attacks or have phobias. These people want to flee the situation at the first sign of anxiety.

Further Examples

Further examples of coping strategies include emotional or instrumental support, self-distraction, denial, substance use, self-blame, behavioural disengagement and the use of drugs or alcohol.

Many people think that meditation “not only calms our emotions, but…makes us feel more ‘together'”, as too can “the kind of prayer in which you’re trying to achieve an inner quietness and peace”.

Low-effort syndrome or low-effort coping refers to the coping responses of a person refusing to work hard. For example, a student at school may learn to put in only minimal effort as they believe if they put in effort it could unveil their flaws.

Historical Psychoanalytic Theories

Otto Fenichel

Otto Fenichel summarised early psychoanalytic studies of coping mechanisms in children as “a gradual substitution of actions for mere discharge reactions…[&] the development of the function of judgement” – noting however that “behind all active types of mastery of external and internal tasks, a readiness remains to fall back on passive-receptive types of mastery.”

In adult cases of “acute and more or less ‘traumatic’ upsetting events in the life of normal persons”, Fenichel stressed that in coping, “in carrying out a ‘work of learning’ or ‘work of adjustment’, [s]he must acknowledge the new and less comfortable reality and fight tendencies towards regression, towards the misinterpretation of reality”, though such rational strategies “may be mixed with relative allowances for rest and for small regressions and compensatory wish fulfillment, which are recuperative in effect”.

Karen Horney

In the 1940s, the German Freudian psychoanalyst Karen Horney “developed her mature theory in which individuals cope with the anxiety produced by feeling unsafe, unloved, and undervalued by disowning their spontaneous feelings and developing elaborate strategies of defence.” Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states.

The healthy strategy she termed “Moving with” is that with which psychologically healthy people develop relationships. It involves compromise. In order to move with, there must be communication, agreement, disagreement, compromise, and decisions. The three other strategies she described – “Moving toward”, “Moving against” and “Moving away” – represented neurotic, unhealthy strategies people utilise in order to protect themselves.

Horney investigated these patterns of neurotic needs (compulsive attachments). The neurotics might feel these attachments more strongly because of difficulties within their lives. If the neurotic does not experience these needs, they will experience anxiety. The ten needs are:

  • Affection and approval, the need to please others and be liked.
  • A partner who will take over one’s life, based on the idea that love will solve all of one’s problems.
  • Restriction of one’s life to narrow borders, to be undemanding, satisfied with little, inconspicuous; to simplify one’s life.
  • Power, for control over others, for a façade of omnipotence, caused by a desperate desire for strength and dominance.
  • Exploitation of others; to get the better of them.
  • Social recognition or prestige, caused by an abnormal concern for appearances and popularity.
  • Personal admiration.
  • Personal achievement.
  • Self-sufficiency and independence.
  • Perfection and unassailability, a desire to be perfect and a fear of being flawed.

In Compliance, also known as “Moving toward” or the “Self-effacing solution”, the individual moves towards those perceived as a threat to avoid retribution and getting hurt, “making any sacrifice, no matter how detrimental.” The argument is, “If I give in, I won’t get hurt.” This means that: if I give everyone I see as a potential threat whatever they want, I won’t be injured (physically or emotionally). This strategy includes neurotic needs one, two, and three.

In Withdrawal, also known as “Moving away” or the “Resigning solution”, individuals distance themselves from anyone perceived as a threat to avoid getting hurt – “the ‘mouse-hole’ attitude … the security of unobtrusiveness.” The argument is, “If I do not let anyone close to me, I won’t get hurt.” A neurotic, according to Horney desires to be distant because of being abused. If they can be the extreme introvert, no one will ever develop a relationship with them. If there is no one around, nobody can hurt them. These “moving away” people fight personality, so they often come across as cold or shallow. This is their strategy. They emotionally remove themselves from society. Included in this strategy are neurotic needs three, nine, and ten.

In Aggression, also known as the “Moving against” or the “Expansive solution”, the individual threatens those perceived as a threat to avoid getting hurt. Children might react to parental in-differences by displaying anger or hostility. This strategy includes neurotic needs four, five, six, seven, and eight.

Related to the work of Karen Horney, public administration scholars[40] developed a classification of coping by frontline workers when working with clients (see also the work of Michael Lipsky on street-level bureaucracy). This coping classification is focused on the behavior workers can display towards clients when confronted with stress. They show that during public service delivery there are three main families of coping:

  • Moving towards clients:
    • Coping by helping clients in stressful situations.
    • An example is a teacher working overtime to help students.
  • Moving away from clients:
    • Coping by avoiding meaningful interactions with clients in stressful situations.
    • An example is a public servant stating “the office is very busy today, please return tomorrow.”
  • Moving against clients:
    • Coping by confronting clients.
    • For instance, teachers can cope with stress when working with students by imposing very rigid rules, such as no phone use in class and sending everyone to the office when they use a phone.
    • Furthermore, aggression towards clients is also included here.

In their systematic review of 35 years of the literature, the scholars found that the most often used family is moving towards clients (43% of all coping fragments). Moving away from clients was found in 38% of all coping fragments and Moving against clients in 19%.

Heinz Hartmann

In 1937, the psychoanalyst (as well as a physician, psychologist, and psychiatrist) Heinz Hartmann marked it as the evolution of ego psychology by publishing his paper, “Me” (which was later translated into English in 1958, titled, “The Ego and the Problem of Adaptation”). Hartmann focused on the adaptive progression of the ego “through the mastery of new demands and tasks”. In fact, according to his adaptive point of view, once infants were born they have the ability to be able to cope with the demands of their surroundings. In his wake, ego psychology further stressed “the development of the personality and of ‘ego-strengths’…adaptation to social realities”.

Object Relations

Emotional intelligence has stressed the importance of “the capacity to soothe oneself, to shake off rampant anxiety, gloom, or irritability….People who are poor in this ability are constantly battling feelings of distress, while those who excel in it can bounce back far more quickly from life’s setbacks and upsets”. From this perspective, “the art of soothing ourselves is a fundamental life skill; some psychoanalytic thinkers, such as John Bowlby and D. W. Winnicott see this as the most essential of all psychic tools.”

Object relations theory has examined the childhood development both of “[i]ndependent coping…capacity for self-soothing”, and of “[a]ided coping. Emotion-focused coping in infancy is often accomplished through the assistance of an adult.”

Gender Differences

Gender differences in coping strategies are the ways in which men and women differ in managing psychological stress. There is evidence that males often develop stress due to their careers, whereas females often encounter stress due to issues in interpersonal relationships. Early studies indicated that “there were gender differences in the sources of stressors, but gender differences in coping were relatively small after controlling for the source of stressors”; and more recent work has similarly revealed “small differences between women’s and men’s coping strategies when studying individuals in similar situations.”

In general, such differences as exist indicate that women tend to employ emotion-focused coping and the “tend-and-befriend” response to stress, whereas men tend to use problem-focused coping and the “fight-or-flight” response, perhaps because societal standards encourage men to be more individualistic, while women are often expected to be interpersonal. An alternative explanation for the aforementioned differences involves genetic factors. The degree to which genetic factors and social conditioning influence behaviour, is the subject of ongoing debate.

Physiological Basis

Hormones also play a part in stress management. Cortisol, a stress hormone, was found to be elevated in males during stressful situations. In females, however, cortisol levels were decreased in stressful situations, and instead, an increase in limbic activity was discovered. Many researchers believe that these results underlie the reasons why men administer a fight-or-flight reaction to stress; whereas, females have a tend-and-befriend reaction. The “fight-or-flight” response activates the sympathetic nervous system in the form of increased focus levels, adrenaline, and epinephrine. Conversely, the “tend-and-befriend” reaction refers to the tendency of women to protect their offspring and relatives. Although these two reactions support a genetic basis to differences in behaviour, one should not assume that in general females cannot implement “fight-or-flight” behaviour or that males cannot implement “tend-and-befriend” behaviour. Additionally, this study implied differing health impacts for each gender as a result of the contrasting stress-processes.

What is Defence Mechanism?

Published on by Andrew Marshall42 Comments

Introduction

In psychoanalytic theory, a defence mechanism is an unconscious psychological mechanism that reduces anxiety arising from unacceptable or potentially harmful stimuli.

Defence mechanisms may result in healthy or unhealthy consequences depending on the circumstances and frequency with which the mechanism is used. Defence mechanisms (German: Abwehrmechanismen) are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses and to maintain one’s self-schema or other schemas. These processes that manipulate, deny, or distort reality may include the following: repression, or the burying of a painful feeling or thought from one’s awareness even though it may resurface in a symbolic form; identification, incorporating an object or thought into oneself; and rationalisation, the justification of one’s behaviour and motivations by substituting “good” acceptable reasons for the actual motivations. In psychoanalytic theory, repression is considered the basis for other defence mechanisms.

Healthy people normally use different defence mechanisms throughout life. A defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected. Among the purposes of ego defence mechanisms is to protect the mind/self/ego from anxiety or social sanctions or to provide a refuge from a situation with which one cannot currently cope.

One resource used to evaluate these mechanisms is the Defence Style Questionnaire (DSQ-40) (see here for online version).

Refer to Coping (Psychology).

Theories and Classifications

Different theorists have different categorisations and conceptualisations of defence mechanisms. Large reviews of theories of defence mechanisms are available from Paulhus, Fridhandler and Hayes (1997) and Cramer (1991). The Journal of Personality published a special issue on defence mechanisms (1998).

In the first definitive book on defence mechanisms, The Ego and the Mechanisms of Defence (1936), Anna Freud enumerated the ten defence mechanisms that appear in the works of her father, Sigmund Freud: repression, regression, reaction formation, isolation, undoing, projection, introjection, turning against one’s own person, reversal into the opposite, and sublimation or displacement.

Sigmund Freud posited that defence mechanisms work by distorting id impulses into acceptable forms, or by unconscious or conscious blockage of these impulses. Anna Freud considered defence mechanisms as intellectual and motor automatisms of various degrees of complexity, that arose in the process of involuntary and voluntary learning.

Anna Freud introduced the concept of signal anxiety; she stated that it was “not directly a conflicted instinctual tension but a signal occurring in the ego of an anticipated instinctual tension”. The signalling function of anxiety was thus seen as crucial, and biologically adapted to warn the organism of danger or a threat to its equilibrium. The anxiety is felt as an increase in bodily or mental tension, and the signal that the organism receives in this way allows for the possibility of taking defensive action regarding the perceived danger.

Both Freuds studied defence mechanisms, but Anna spent more of her time and research on five main mechanisms: repression, regression, projection, reaction formation, and sublimation. All defence mechanisms are responses to anxiety and how the consciousness and unconscious manage the stress of a social situation.

  • Repression: when a feeling is hidden and forced from the consciousness to the unconscious because it is seen as socially unacceptable.
  • Regression: falling back into an early state of mental/physical development seen as “less demanding and safer”.
  • Projection: possessing a feeling that is deemed as socially unacceptable and instead of facing it, that feeling or “unconscious urge” is seen in the actions of other people.
  • Reaction formation: acting the opposite way that the unconscious instructs a person to behave, “often exaggerated and obsessive”.
    • For example, if a wife is infatuated with a man who is not her husband, reaction formation may cause her to – rather than cheat – become obsessed with showing her husband signs of love and affection.
  • Sublimation: seen as the most acceptable of the mechanisms, an expression of anxiety in socially acceptable ways.

Otto F. Kernberg (1967) developed a theory of borderline personality organisation of which one consequence may be borderline personality disorder. His theory is based on ego psychological object relations theory. Borderline personality organisation develops when the child cannot integrate helpful and harmful mental objects together. Kernberg views the use of primitive defence mechanisms as central to this personality organisation. Primitive psychological defences are projection, denial, dissociation or splitting and they are called borderline defence mechanisms. Also, devaluation and projective identification are seen as borderline defences.

In George Eman Vaillant’s (1977) categorisation, defences form a continuum related to their psychoanalytical developmental level. They are classified into pathological, immature, neurotic and “mature” defences.

Robert Plutchik’s (1979) theory views defences as derivatives of basic emotions, which in turn relate to particular diagnostic structures. According to his theory, reaction formation relates to joy (and manic features), denial relates to acceptance (and histrionic features), repression to fear (and passivity), regression to surprise (and borderline traits), compensation to sadness (and depression), projection to disgust (and paranoia), displacement to anger (and hostility) and intellectualisation to anticipation (and obsessionality).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association (1994) included a tentative diagnostic axis for defence mechanisms. This classification is largely based on Vaillant’s hierarchical view of defences, but has some modifications. Examples include: denial, fantasy, rationalisation, regression, isolation, projection, and displacement.

Vaillant’s Categorisation

Psychiatrist George Eman Vaillant introduced a four-level classification of defence mechanisms: Much of this is derived from his observations while overseeing the Grant study that began in 1937 and is on-going. In monitoring a group of men from their freshman year at Harvard until their deaths, the purpose of the study was to see longitudinally what psychological mechanisms proved to have impact over the course of a lifetime. The hierarchy was seen to correlate well with the capacity to adapt to life. His most comprehensive summary of the on-going study was published in 1977.The focus of the study is to define mental health rather than disorder.

  • Level 1: Pathological defences (psychotic denial, delusional projection).
  • Level 2: Immature defences (fantasy, projection, passive aggression, acting out).
  • Level 3: Neurotic defences (intellectualisation, reaction formation, dissociation, displacement, repression).
  • Level 4: Mature defences (humour, sublimation, suppression, altruism, anticipation).

Level 1: Pathological

When predominant, the mechanisms on this level are almost always severely pathological. These defences, in conjunction, permit one effectively to rearrange external experiences to eliminate the need to cope with reality. Pathological users of these mechanisms frequently appear irrational or insane to others. These are the “pathological” defences, common in overt psychosis. However, they are normally found in dreams and throughout childhood as well. They include:

  • Delusional projection: Delusions about external reality, usually of a persecutory nature.
  • Denial: Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus by stating it does not exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality.
  • Distortion: A gross reshaping of external reality to meet internal needs

Level 2: Immature

These mechanisms are often present in adults. These mechanisms lessen distress and anxiety produced by threatening people or by an uncomfortable reality. Excessive use of such defences is seen as socially undesirable, in that they are immature, difficult to deal with and seriously out of touch with reality. These are the so-called “immature” defences and overuse almost always leads to serious problems in a person’s ability to cope effectively. These defences are often seen in major depression and personality disorders. They include:

  • Acting out: Direct expression of an unconscious wish or impulse in action, without conscious awareness of the emotion that drives the expressive behaviour.
  • Hypochondriasis: An excessive preoccupation or worry about having a serious illness.
  • Passive-aggressive behaviour: Indirect expression of hostility.
  • Projection: A primitive form of paranoia.
    • Projection reduces anxiety by allowing the expression of the undesirable impulses or desires without becoming consciously aware of them; attributing one’s own unacknowledged, unacceptable, or unwanted thoughts and emotions to another; includes severe prejudice and jealousy, hypervigilance to external danger, and “injustice collecting”, all with the aim of shifting one’s unacceptable thoughts, feelings and impulses onto someone else, such that those same thoughts, feelings, beliefs and motivations are perceived as being possessed by the other.
  • Schizoid fantasy: Tendency to retreat into fantasy in order to resolve inner and outer conflicts.

Level 3: Neurotic

These mechanisms are considered neurotic, but fairly common in adults. Such defences have short-term advantages in coping, but can often cause long-term problems in relationships, work and in enjoying life when used as one’s primary style of coping with the world. They include:

  • Displacement: Defence mechanism that shifts sexual or aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening.
  • Dissociation: Temporary drastic modification of one’s personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought.
  • Intellectualisation: A form of isolation; concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects (solitude, rationalisation, ritual, undoing, compensation, and magical thinking)
  • Reaction formation: Converting unconscious wishes or impulses that are perceived to be dangerous or unacceptable into their opposites; behaviour that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety
  • Repression: The process of attempting to repel desires towards pleasurable instincts, caused by a threat of suffering if the desire is satisfied; the desire is moved to the unconscious in the attempt to prevent it from entering consciousness; seemingly unexplainable naivety, memory lapse or lack of awareness of one’s own situation and condition; the emotion is conscious, but the idea behind it is absent.

Level 4: Mature

These are commonly found among emotionally healthy adults and are considered mature, even though many have their origins in an immature stage of development. They are conscious processes, adapted through the years in order to optimise success in human society and relationships. The use of these defences enhances pleasure and feelings of control. These defences help to integrate conflicting emotions and thoughts, whilst still remaining effective. Those who use these mechanisms are usually considered virtuous. Mature defences include:

  • Altruism: Constructive service to others that brings pleasure and personal satisfaction.
  • Anticipation: Realistic planning for future discomfort.
  • Humour: Overt expression of ideas and feelings (especially those that are unpleasant to focus on or too terrible to talk about directly) that gives pleasure to others. The thoughts retain a portion of their innate distress, but they are “skirted around” by witticism, for example, self-deprecation.
  • Sublimation: Transformation of unhelpful emotions or instincts into healthy actions, behaviours, or emotions, for example, playing a heavy contact sport such as football or rugby can transform aggression into a game.
  • Suppression: The conscious decision to delay paying attention to a thought, emotion, or need in order to cope with the present reality; making it possible later to access uncomfortable or distressing emotions whilst accepting them.

Other Defence Mechanisms

Pathological

  • Conversion:
    • The expression of an intrapsychic conflict as a physical symptom; examples include blindness, deafness, paralysis, or numbness.
    • This phenomenon is sometimes called hysteria.
  • Splitting:
    • A primitive defence.
    • Both harmful and helpful impulses are split off and segregated, frequently projected onto someone else.
    • The defended individual segregates experiences into all-good and all-bad categories, with no room for ambiguity and ambivalence.
    • When “splitting” is combined with “projecting”, the undesirable qualities that one unconsciously perceives oneself as possessing, one consciously attributes to another.

Immature

  • Idealisation:
    • Tending to perceive another individual as having more desirable qualities than he or she may actually have.
  • Introjection:
    • Identifying with some idea or object so deeply that it becomes a part of that person.
    • For example, introjection occurs when we take on attributes of other people who seem better able to cope with the situation than we do.
  • Projective identification:
    • The object of projection invokes in that person a version of the thoughts, feelings or behaviours projected.
  • Somatisation:
    • The transformation of uncomfortable feelings towards others into uncomfortable feelings toward oneself: pain, illness, and anxiety.
  • Wishful thinking:
    • Making decisions according to what might be pleasing to imagine instead of by appealing to evidence, rationality, or reality.

Neurotic

  • Isolation:
    • Separation of feelings from ideas and events, for example, describing a murder with graphic details with no emotional response.
  • Rationalisation (making excuses):
    • Convincing oneself that no wrong has been done and that all is or was all right through faulty and false reasoning.
    • An indicator of this defence mechanism can be seen socially as the formulation of convenient excuses.
  • Regression:
    • Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way, for example, using whining as a method of communicating despite already having acquired the ability to speak with an appropriate level of maturity.
  • Undoing:
    • A person tries to ‘undo’ an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable. Involves symbolically nullifying an unacceptable or guilt provoking thought, idea, or feeling by confession or atonement.
  • Upward and downward social comparisons:
    • A defensive tendency that is used as a means of self-evaluation. Individuals will look to another individual or comparison group who are considered to be worse off in order to dissociate themselves from perceived similarities and to make themselves feel better about themselves or their personal situation.
  • Withdrawal:
    • Avoidance is a form of defence.
    • It entails removing oneself from events, stimuli, and interactions under the threat of being reminded of painful thoughts and feelings.

Relation with Coping

There are many different perspectives on how the construct of defence relates to the construct of coping; some writers differentiate the constructs in various ways, but “an important literature exists that does not make any difference between the two concepts”. In at least one of his books, George Eman Vaillant stated that he “will use the terms adaptation, resilience, coping, and defense interchangeably”.

Refer to Coping (Psychology).

On This Day … 01 April

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People (Births)

  • 1908 – Abraham Maslow, American psychologist and academic (d. 1970).

People (Deaths)

  • 1922 – Hermann Rorschach, Swiss psychologist and author (b. 1884).

Abraham Maslow

Abraham Harold Maslow (01 April 1908 to 08 June 1970) was an American psychologist who was best known for creating Maslow’s hierarchy of needs, a theory of psychological health predicated on fulfilling innate human needs in priority, culminating in self-actualisation.

Maslow was a psychology professor at Brandeis University, Brooklyn College, New School for Social Research, and Columbia University.

He stressed the importance of focusing on the positive qualities in people, as opposed to treating them as a “bag of symptoms”.

A Review of General Psychology survey, published in 2002, ranked Maslow as the tenth most cited psychologist of the 20th century.

Hermann Rorschach

Hermann Rorschach (08 November 1884 to 02 April 1922) was a Swiss psychiatrist and psychoanalyst.

His education in art helped to spur the development of a set of inkblots that were used experimentally to measure various unconscious parts of the subject’s personality. His method has come to be referred to as the Rorschach test, iterations of which have continued to be used over the years to help identify personality, psychotic, and neurological disorders.

Rorschach continued to refine the test until his premature death at age 37.

What is Catatonia?

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Introduction

Catatonia is a neuropsychiatric behavioural syndrome that is characterised by abnormal movements, immobility, abnormal behaviours, and withdrawal. The onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during episodes. There are several subtypes of catatonia: akinetic catatonia, excited catatonia, malignant catatonia, and other forms.

Although catatonia has historically been related to schizophrenia (catatonic schizophrenia), catatonia is most often seen in mood disorders. It is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurologic, and medical conditions. Catatonia is not a stand-alone diagnosis (although some experts disagree), and the term is used to describe a feature of the underlying disorder.

Recognising and treating catatonia is very important as failure to do this can lead to poor outcomes and can be potentially fatal. Treatment with benzodiazepines or ECT can lead to remission of catatonia. There is growing evidence of the effectiveness of the NMDA receptor antagonists amantadine and memantine for benzodiazepine-resistant catatonia. Antipsychotics are sometimes employed, but they can worsen symptoms and have serious adverse effects.

Brief History

It was first described in 1874 by Karl Ludwig Kahlbaum as Die Katatonie oder das Spannungsirresein (Catatonia or Tension Insanity).

Aetiology/Causes

Catatonia is almost always secondary to another underlying illness, often a psychiatric disorder. Mood disorders such as a bipolar disorder and depression are the most common aetiologies to progress to catatonia. Other psychiatric associations include schizophrenia and other primary psychotic disorders. It also is related to autism spectrum disorders.

Catatonia is also seen in many medical disorders, including infections (such as encephalitis), autoimmune disorders, meningitis, focal neurological lesions (including strokes), alcohol withdrawal, abrupt or overly rapid benzodiazepine withdrawal, cerebrovascular disease, neoplasms, head injury, and some metabolic conditions (homocystinuria, diabetic ketoacidosis, hepatic encephalopathy, and hypercalcaemia).

Epidemiology

Catatonia has been mostly studied in acutely ill psychiatric patients. Catatonia frequently goes unrecognised, leading to the belief that the syndrome is rare, however, this is not true and prevalence has been reported to be as high as 10% in patients with acute psychiatric illnesses. 21-46% of all catatonia cases can be attributed to a general medical condition.

Pathogenesis/Mechanism

The pathophysiology that leads to catatonia is still poorly understood and a definite mechanism remains unknown. Neurologic studies have implicated several pathways, however, it remains unclear whether these findings are the cause or the consequence of the disorder.

Abnormalities in GABA, glutamate signalling, serotonin, and dopamine transmission are believed to be implicated in catatonia.

Furthermore, it has also been hypothesized that pathways that connect the basal ganglia with the cortex and thalamus is involved in the development of catatonia.

Signs and Symptoms

The presentation of a patient with catatonia varies greatly depending on the subtype, underlying cause and it can be acute or subtle.

Because most patients with catatonia have an underlying psychiatric illness, the majority will present with worsening depression, mania, or psychosis followed by catatonia symptoms. Catatonia presents as a motor disturbance in which patients will display marked reduction in movement, marked agitation, or a mixture of both despite having the physical capacity to move normally. These patients may be unable to start an action or stop one. Movements and mannerisms may be repetitive, or purposeless.

The most common signs of catatonia are immobility, mutism, withdrawal and refusal to eat, staring, negativism, posturing (rigidity), rigidity, waxy flexibility/catalepsy, stereotypy (purposeless, repetitive movements), echolalia or echopraxia, verbigeration (repeat meaningless phrases). It should not be assumed that patients presenting with catatonia are unaware of their surroundings as some patients can recall in detail their catatonic state and their actions.

There are several subtypes of catatonia and they are characterised by the specific movement disturbance and associated features. Although catatonia can be divided into various subtypes, the natural history of catatonia is often fluctuant and different states can exist within the same individual.

Subtypes

  • Retarded/Withdrawn Catatonia:
    • This form of catatonia is characterised by decreased response to external stimuli, immobility or inhibited movement, mutism, staring, posturing, and negativism.
    • Patients may sit or stand in the same position for hours, may hold odd positions, and may resist movement of their extremities.
  • Excited Catatonia:
    • Excited catatonia is characterised by odd mannerisms/gestures, performing purposeless or inappropriate actions, excessive motor activity restlessness, stereotypy, impulsivity, agitation, combativeness.
    • Speech and actions may be repetitive or mimic another person’s.
    • People in this state are extremely hyperactive and may have delusions and hallucinations.
    • Catatonic excitement is commonly cited as one of the most dangerous mental states in psychiatry.
  • Malignant Catatonia:
    • Malignant catatonia is a life-threatening condition that may progress rapidly within a few days. It is characterised by fever, abnormalities in blood pressure, heart rate, respiratory rate, diaphoresis (sweating), and delirium.
    • Certain lab findings are common with this presentation, however, they are nonspecific which means that they are also present in other conditions and do not diagnose catatonia.
    • These lab findings include: leukocytosis, elevated creatine kinase, low serum iron.
    • The signs and symptoms of malignant catatonia overlap significantly with neuroleptic malignant syndrome (NMS) and so a careful history, review of medications, and physical exam are critical to properly differentiate these conditions.
    • For example, if the patient has waxy flexibility and holds a position against gravity when passively moved into that position, then it is likely catatonia.
    • If the patient has a “lead-pipe rigidity” then NMS should be the prime suspect.

Diagnosis

There is not yet a definitive consensus regarding diagnostic criteria of catatonia. In the American Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the World Health Organisation’s eleventh edition of the International Classification of Disease (ICD-11) the classification is more homogeneous than in earlier editions. Prominent researchers in the field have other suggestions for diagnostic criteria.

DSM-5 Classification

The DSM-5 does not classify catatonia as an independent disorder, but rather it classifies it as catatonia associated with another mental disorder, due to another medical condition, or as unspecified catatonia. Catatonia is diagnosed by the presence of three or more of the following 12 psychomotor symptoms in association with the above mentioned mental disorder, medical condition, or unspecified.

  • Stupor: no psycho-motor activity; not actively relating to environment.
  • Catalepsy: passive induction of a posture held against gravity.
  • Waxy flexibility: allowing positioning by examiner and maintaining that position.
  • Mutism: no, or very little, verbal response (exclude if known aphasia).
  • Negativism: opposition or no response to instructions or external stimuli.
  • Posturing: spontaneous and active maintenance of a posture against gravity.
  • Mannerisms that are odd, circumstantial caricatures of normal actions.
  • Stereotypy: repetitive, abnormally frequent, non-goal-directed movements.
  • Agitation, not influenced by external stimuli.
  • Grimacing: keeping a fixed facial expression.
  • Echolalia: mimicking another’s speech.
  • Echopraxia: mimicking another’s movements.

Other disorders (additional code 293.89 [F06.1] to indicate the presence of the co-morbid catatonia):

  • Catatonia associated with autism spectrum disorder.
  • Catatonia associated with schizophrenia spectrum and other psychotic disorders.
  • Catatonia associated with brief psychotic disorder.
  • Catatonia associated with schizophreniform disorder.
  • Catatonia associated with schizoaffective disorder.
  • Catatonia associated with substance-induced psychotic disorder.
  • Catatonia associated with bipolar and related disorders.
  • Catatonia associated with major depressive disorder.
  • Catatonic disorder due to another medical condition.
  • If catatonic symptoms are present but do not form the catatonic syndrome, a medication- or substance-induced aetiology should first be considered.

ICD-11 Classification

In ICD-11 catatonia is defined as a syndrome of primarily psychomotor disturbances that is characterised by the simultaneous occurrence of several symptoms such as stupor; catalepsy; waxy flexibility; mutism; negativism; posturing; mannerisms; stereotypies; psychomotor agitation; grimacing; echolalia and echopraxia. Catatonia may occur in the context of specific mental disorders, including mood disorders, schizophrenia or other primary psychotic disorders, and Neurodevelopmental disorders, and may be induced by psychoactive substances, including medications. Catatonia may also be caused by a medical condition not classified under mental, behavioural, or neurodevelopmental disorders.

Assessment/Physical

Catatonia is often overlooked and under-diagnosed. Patients with catatonia most commonly have an underlying psychiatric disorder, for this reason, physicians may overlook signs of catatonia due to the severity of the psychosis the patient is presenting with. Furthermore, the patient may not be presenting with the common signs of catatonia such as mutism and posturing. Additionally, the motor abnormalities seen in catatonia are also present in psychiatric disorders. For example, a patient with mania will show increased motor activity that may progress to excited catatonia. One way in which physicians can differentiate between the two is to observe the motor abnormality. Patients with mania present with increased goal-directed activity. On the other hand, the increased activity in catatonia is not goal-directed and often repetitive.

Catatonia is a clinical diagnosis and there is no specific laboratory test to diagnose it. However, certain testing can help determine what is causing the catatonia. An EEG will likely show diffuse slowing. If a seizure activity is driving the syndrome, then an EEG would also be helpful in detecting this. CT or MRI will not show catatonia; however, they might reveal abnormalities that might be leading to the syndrome. Metabolic screens, inflammatory markers, or autoantibodies may reveal reversible medical causes of catatonia.

Vital signs should be frequently monitored as catatonia can progress to malignant catatonia which is life-threatening. Malignant catatonia is characterised by fever, hypertension, tachycardia, and tachypnoea.

Rating Scale

Various rating scales for catatonia have been developed, however, their utility for clinical care has not been well established. The most commonly used scale is the Bush-Francis Catatonia Rating Scale (BFCRS) (downloadable PDF). The scale is composed of 23 items with the first 14 items being used as the screening tool. If 2 of the 14 are positive, this prompts for further evaluation and completion of the remaining 9 items.

A diagnosis can be supported by the lorazepam challenge or the zolpidem challenge. While proven useful in the past, barbiturates are no longer commonly used in psychiatry; thus the option of either benzodiazepines or ECT.

Differential Diagnosis

The differential diagnosis of catatonia is extensive as signs and symptoms of catatonia may overlap significantly with those of other conditions. Therefore, a careful and detailed history, medication review, and physical exam are key to diagnosing catatonia and differentiating it from other conditions. Furthermore, some of these conditions can themselves lead to catatonia. The differential diagnosis is as follows:

  • Neuroleptic malignant syndrome (NMS):
    • Malignant catatonia and NMS are both life-threatening conditions that share many of the same characteristics including fever, autonomic instability, rigidity, and delirium.
    • Lab values of low serum iron, elevated creatine kinase, and white blood cell count are also shared by the two disorders further complicating the diagnosis.
    • Some experts consider NMS a drug-induced form of catatonia, however, it has not been established as a subtype.
    • There are features of malignant catatonia (posturing, impulsivity, etc) that are absent from NSM and the lab results are not as consistent in malignant catatonia as they are in NMS.
    • NMS is a drug-induced condition associated with antipsychotics, particularly, first generation antipsychotics.
    • Therefore, discontinuing antipsychotics and starting benzodiazepines is a treatment for this condition, and similarly it is helpful in catatonia as well.
  • Anti-NMDA receptor encephalitis:
    • Anti-NMDA receptor encephalitis is an autoimmune disorder characterised by neuropsychiatric features and the presence of IgG antibodies.
    • The presentation of anti-NMDAR encephalitis has been categorized into 5 phases: prodromal phase, psychotic phase, unresponsive phase, hyperkinetic phase, and recovery phase.
    • The psychotic phase progresses into the unresponsive phase characterized by mutism, decreased motor activity, and catatonia.
  • Serotonin syndrome:
    • Both serotonin syndrome and malignant catatonia may present with signs and symptoms of delirium, autonomic instability, hyperthermia, and rigidity.
    • Again, similar to the presentation in NSM. However, patients with Serotonin syndrome have a history of ingestion of serotonergic drugs (Ex: SSRI).
    • These patients will also present with hyperreflexia, myoclonus, nausea, vomiting, and diarrhoea.
  • Malignant hyperthermia:
    • Malignant hyperthermia and malignant catatonia share features of autonomic instability, hyperthermia, and rigidity.
    • However, malignant hyperthermia is a hereditary disorder of skeletal muscle that makes these patients susceptible to exposure to halogenated anaesthetics and/or depolarising muscle relaxants like succinylcholine.
    • Malignant hyperthermia most commonly occurs in the intraoperative or postoperative periods. Other signs and symptoms of malignant hyperthermia include metabolic and respiratory acidosis, hyperkalaemia, and cardiac arrhythmias.
  • Akinetic mutism:
    • Akinetic mutism is a neurological disorder characterised by a decrease in goal-directed behaviour and motivation, however, the patient has an intact level of consciousness.
    • Patients may present with apathy, and may seem indifferent to pain, hunger, or thirst.
    • Akinetic mutism has been associated with structural damage in a variety of brain areas.
    • Akinetic mutism and catatonia may both manifest with immobility, mutism, and waxy flexibility.
    • Differentiating both disorders is the fact that akinetic mutism does not present with echolalia, echopraxia, or posturing.
    • Furthermore, it is not responsive to benzodiazepines as is the case for catatonia.
  • Elective mutism:
    • Elective mutism has an anxious aetiology but has also been associated with personality disorders.
    • Patients with this disorder fail to speak with some individuals but will speak with others.
    • Likewise, they may refuse to speak in certain situations, for example, a child who refuses to speak at school but is conversational at home.
    • This disorder is distinguished from catatonia by the absence of any other signs/symptoms.
  • Non-convulsive status epilepticus:
    • Non-convulsive status epilepticus is seizure activity with no accompanying tonic-clonic movements.
    • It can present with stupor, similar to catatonia, and they both respond to benzodiazepines.
    • Non-convulsive status epilepticus is diagnosed by the presence of seizure activity seen on electroencephalogram (EEG).
    • Catatonia on the other hand, is associated with normal EEG or diffuse slowing.
  • Delirium:
    • Delirium is characterised by fluctuating disturbed perception and consciousness in the ill individual.
    • It has hypoactive and hyperactive or mixed forms. People with hyperactive delirium present similarly to those with excited catatonia and have symptoms of restlessness, agitation and aggression.
    • Those with hypoactive delirium present with similarly to retarded catatonia, withdrawn and quiet.
    • However, catatonia also includes other distinguishing features including posturing and rigidity as well as a positive response to benzodiazepines.
  • Locked-in syndrome:
    • Patients with locked-in syndrome present with immobility and mutism, however, unlike patients with catatonia who are unmotivated to communicate, patients with locked-in syndrome try to communicate with eye movements and blinking.
    • Furthermore, locked-in syndrome is caused by damage to the brainstem.
  • Stiff-person syndrome:
    • Catatonia and stiff-person syndrome are similar in that they may both present with rigidity, autonomic instability and a positive response to benzodiazepines.
    • However, stiff-person syndrome may be associated with anti-glutamic acid decarboxylase (anti-GAD) antibodies and other catatonic signs such as mutism and posturing are not part of the syndrome.
  • Parkinson’s disease:
    • Untreated late-stage Parkinson’s disease may present similarly to retarded catatonia with symptoms of immobility, rigidity, and difficulty speaking.
    • Further complicating the diagnosis is the fact that many patients with Parkinson’s disease will have major depressive disorder which may be the underlying cause of catatonia.
    • Parkinson’s disease can be distinguished from catatonia by a positive response to levodopa.
    • Catatonia on the other hand will show a positive response to benzodiazepines.

Treatment

The initial treatment of catatonia is to stop medication that could be potentially leading to the syndrome. These may include steroids, stimulants, anticonvulsants, neuroleptics, dopamine blockers, etc. The next step is to provide a “lorazepam challenge,” in which patients are given 2 mg of IV lorazepam (or another benzodiazepine). Most patients with catatonia will respond significantly to this within the first 15-30 minutes. If no change is observed during the first dose, then a second dose is given and the patient is re-examined. If the patient responds to the lorazepam challenge, then lorazepam can be scheduled at interval doses until the catatonia resolves. The lorazepam must be tapered slowly, otherwise, the catatonia symptoms may return. The underlying cause of the catatonia should also be treated during this time. If within a week the catatonia is not resolved, then ECT can be used to reverse the symptoms. ECT in combination with benzodiazepines is used to treat malignant catatonia. In France, zolpidem has also been used in diagnosis, and response may occur within the same time period. Ultimately the underlying cause needs to be treated.

Electroconvulsive therapy (ECT) is an effective treatment for catatonia that is well acknowledged. ECT has also shown favourable outcomes in patients with chronic catatonia. However, it has been pointed out that further high quality randomised controlled trials are needed to evaluate the efficacy, tolerance, and protocols of ECT in catatonia.

Antipsychotics should be used with care as they can worsen catatonia and are the cause of neuroleptic malignant syndrome, a dangerous condition that can mimic catatonia and requires immediate discontinuation of the antipsychotic.

Excessive glutamate activity is believed to be involved in catatonia; when first-line treatment options fail, NMDA antagonists such as amantadine or memantine may be used. Amantadine may have an increased incidence of tolerance with prolonged use and can cause psychosis, due to its additional effects on the dopamine system. Memantine has a more targeted pharmacological profile for the glutamate system, reduced incidence of psychosis and may therefore be preferred for individuals who cannot tolerate amantadine. Topiramate is another treatment option for resistant catatonia; it produces its therapeutic effects by producing glutamate antagonism via modulation of AMPA receptors.

Complications, Outcomes, and Recurrence

Patients may suffer several complications from being in a catatonic state. The nature of these complications will depend on the type of catatonia being experienced by the patient. For example, patients presenting with retarded catatonia may have refusal to eat which will in turn lead to malnutrition and dehydration. Furthermore, if immobility is a symptom the patient is presenting with, then they may develop pressure ulcers, muscle contractions, and are at risk of developing deep vein thrombosis (DVT) and pulmonary embolus (PE). Patients with excited catatonia may be aggressive and violent, and physical trauma may result from this. Catatonia may progress to the malignant type which will present with autonomic instability and may be life threatening. Other complications also include the development of pneumonia and neuroleptic malignant syndrome.[2]

Patients who experience an episode of catatonia are more likely to suffer recurrence. Treatment response for patients with catatonia is 50-70% and these patients have a good prognosis. However, failure to respond to medication is a very poor prognosis. Many of these patients will require long-term and continuous mental health care. For patients with catatonia with underlying schizophrenia, the prognosis is much poorer.

On This Day … 31 March

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People (Births)

  • 1930 – Yehuda Nir, Polish Jewish-American psychiatrist (d. 2014).

Yehuda Nir

Yehuda Nir (31 March 1930 to 19 July 2014) was a Polish-born American Holocaust survivor, psychiatrist and author of The Lost Childhood. Nir posed as a Roman Catholic and learned Latin to escape Nazi persecution in Poland during World War II. Nir’s ordeal led him to a career as a psychiatrist, specialising in the treatment of post-traumatic stress disorder and severely ill children. He immigrated to the United States in 1959 to complete medical residencies in New York City and Philadelphia. He served as the chief of child psychiatry of Memorial Sloan-Kettering Cancer Center from 1979 until 1986.

Nir was born Juliusz Gruenfeld in Lwów, Poland, (present-day Lviv, Ukraine) on 31 March 1930. He later changed his name to “Nir” after World War II since “Gruenfeld” has German origins. Nir means ‘plowed fields’ in Hebrew.

Nir released a memoir of his experience during the Holocaust, “The Lost Childhood”, in 1989. A second edition was reprinted by Scholastic Press in 2002. The Lost Childhood is now used as part of the high school curriculum throughout the United States. He also published four self-help books focusing on relationships, including “Not Quite Paradise: Making Marriage Work” and “Loving Men for All the Right Reasons.”

Yehuda Nir died at his home in Manhattan, New York City, on 19 July 2014, at the age of 84. His funeral was held at Riverside Memorial Chapel on the Upper West Side, with burial on the Mount of Olives in Jerusalem. He was survived by his wife Bonnie Maslin and their children: daughter Sarah, a reporter for The New York Times; and son David, the political director of Daily Kos; and two sons from a previous marriage: private investor Daniel and fashion executive Aaron.

What is Behaviour Therapy?

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Introduction

Behaviour therapy or behavioural psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviourism and/or cognitive psychology.

It looks at specific, learned behaviours and how the environment, or other people’s mental states, influences those behaviours, and consists of techniques based on learning theory, such as respondent or operant conditioning. Behaviourists who practice these techniques are either behaviour analysts or cognitive-behavioural therapists. They tend to look for treatment outcomes that are objectively measurable. Behaviour therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person’s psychological problems.

Behavioural psychotherapy is sometimes juxtaposed with cognitive psychotherapy, while cognitive behavioural therapy integrates aspects of both approaches, such as cognitive restructuring, positive reinforcement, habituation (or desensitisation), counterconditioning, and modelling.

Applied behaviour analysis (ABA) is the application of behaviour analysis that focuses on functionally assessing how behaviour is influenced by the observable learning environment and how to change such behaviour through contingency management or exposure therapies, which are used throughout clinical behaviour analysis therapies or other interventions based on the same learning principles.

Cognitive-behavioural therapy views cognition and emotions as preceding overt behaviour and implements treatment plans in psychotherapy to lessen the issue by managing competing thoughts and emotions, often in conjunction with behavioural learning principles.

A 2013 Cochrane review comparing behaviour therapies to psychological therapies found them to be equally effective, although at the time the evidence base that evaluates the benefits and harms of behaviour therapies was felt to be weak.

Brief History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behaviour or Learning makes frequent use of the term “modifying behaviour”. Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term “behaviour therapy” was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner’s group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner’s student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing programme called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy’s enduring commitment to the principles of behavioural therapy and biofeedback.

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and Donald Meichenbaum to form cognitive behaviour therapy (CBT). In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical Basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has, but consider that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviours.

Contingency management programmes are a direct product of research from operant conditioning.

Current Forms

Behavioural therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behaviour analysis. Behavioural psychotherapy has become increasingly contextual in recent years. Behavioural psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualisations.

Functional Analytic Psychotherapy

One current form of behavioural psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behaviour therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioural psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviourism and functional contextualism.

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behaviour therapy and cognitive behavioural therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client’s problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client’s progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person’s answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a persons behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment “person variables” are also considered. These “person variables” come from a person’s social learning history and they affect the way in which the environment affects that person’s behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions:

  1. What are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour; and
  2. What type of behaviour therapy or technique that can help the individual improve most effectively.

The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical Applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of a person with an alcohol use disorder, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitisation, virtual reality exposure, exposure and response prevention techniques, social skills training, modelling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitisation is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitisation is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitisation it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modelling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the “model person” as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures:

  1. The procedures are used to decrease the likelihood of the frequency of a certain behaviour; and
  2. Procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them.

The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward.

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis:

  • First behaviour analysis is focused mainly on overt behaviours in an applied setting.
    • Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.
  • Another characteristic of applied behaviour analysis is how it (behaviour analysis) goes about evaluating treatment effects.
    • The individual subject is where the focus of study is on, the investigation is centred on the one individual being treated.
  • A third characteristic is that it focuses on what the environment does to cause significant behaviour changes.
  • Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programmes have generally lost favour.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life’s tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective there must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won’t expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In Rehabilitation

Currently, there is a greater call for behavioural psychologists to be involved in rehabilitation efforts.

Treatment of Mental Disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics.

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitisation has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitisation does not occur over night, there is a process of treatment. Desensitisation is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modelling has been used in dealing with fears and phobias. Modelling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations as well as alcohol use disorder.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn’t focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment Outcomes

Systematic desensitisation has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitisation is an effective technique that can be applied to a number of problems that a person may have.

When using modelling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitisation, the modelling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modelling the greater the effectiveness of the treatment.

While undergoing exposure therapy, a person typically needs five sessions to assess the treatment’s effectiveness. After five sessions, exposure treatment has been shown to provide benefit to the patient. However, it is still recommended treatment continue beyond the initial five sessions.

Virtual reality therapy (VRT) has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Due to the costs associated with VRT, therapists are still awaiting results of controlled trials investigating VRT, to assess which applications demonstrate the best results.

For those with suicidal ideation, treatment depends on how severe the person’s depression and sense of hopelessness is. If these things are severe, the person’s response to completing small steps will not be of importance to them, because they don’t consider the success an accomplishment. Generally, in those not suffering from severe depression or fear, this technique has been successful, as completion of simpler activities builds their confidences and allows them to progress to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

Third Generation

The third-generation behaviour therapy movement has been called clinical behaviour analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioural analysis system of psychotherapy (CBASP), behavioural activation (BA), dialectical behavioural therapy, functional analytic psychotherapy (FAP), integrative behavioural couples therapy, metacognitive therapy and metacognitive training. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. Other authors object to the term “third generation” or “third wave” and incorporate many of the “third wave” therapeutic techniques under the general umbrella term of modern cognitive behavioural therapies.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1969) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple’s relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Organisations

Many organisations exist for behaviour therapists around the world. In the United States, the American Psychological Association’s Division 25 is the division for behaviour analysis. The Association for Contextual Behaviour Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behaviour analysts who are psychologists belong to American Psychological Association’s division 25 – Behaviour analysis. APA offers a diploma in behavioural psychology.

The Association for Behavioural and Cognitive Therapies (formerly the Association for the Advancement of Behaviour Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behaviour analysis, which focuses on clinical behaviour analysis. In addition, the Association for Behavioural an Cognitive Therapies has a special interest group on addictions.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Training

Recent efforts in behavioural psychotherapy have focused on the supervision process. A key point of behavioural models of supervision is that the supervisory process parallels the behavioural psychotherapy.

Methods

  • Behaviour management.
  • Behaviour modification.
  • Clinical behaviour analysis.
  • Contingency management.
  • Covert conditioning.
  • Decoupling.
  • Exposure and response prevention.
  • Flooding.
  • Habit reversal training.
  • Matching law.
  • Modelling.
  • Observational learning.
  • Operant conditioning.
  • Professional practice of behaviour analysis.
  • Respondent conditioning.
  • Stimulus control.
  • Systematic desensitisation.

Reference

Skinner, B.F. (1969). Contingencies of Reinforcement: A Theoretical Analysis. New York: Meredith Corporation.